Healthcare Provider Details

I. General information

NPI: 1851181663
Provider Name (Legal Business Name): GLY COMMUNITY SUPPORT SERVICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2025
Last Update Date: 05/07/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1646 PORTER LAKES DR
JACKSONVILLE FL
32218-8321
US

IV. Provider business mailing address

1646 PORTER LAKES DR
JACKSONVILLE FL
32218-8321
US

V. Phone/Fax

Practice location:
  • Phone: 904-758-6333
  • Fax:
Mailing address:
  • Phone: 904-758-6333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code344600000X
TaxonomyTaxi
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code347B00000X
TaxonomyBus
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: MRS. LAKESHA TYJUAN HOLMES
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 904-758-6333